Relationship between Circadian Variation in Ictus of Aneurysmal Subarachnoid Hemorrhage and Physical Activity

OBJECTIVE: The circadian pattern of the onset time of aneurysmal subarachnoid hemorrhage (aSAH) has been reported by various authors. However, the effect of the degree of physical exertion on the circadian pattern has not been studied in detail. Therefore, we conducted this study to investigate the effect of physical exertion on the circadian pattern of aSAH.METHODS: Of the 335 patients presenting with aSAH from January 2012 to December 2017, 234 patients with identifiable onset time and metabolic equivalent (MET) values were enrolled. The onset time of aSAH was divided into 4-hour intervals. The patient’s physical exertion was then assessed on a scale between 1 and 8 METs using generally accepted MET values, and categorized into two groups—light exertion (1 to 4 METs) and moderate to heavy exertion (5 to 8 METs)—to determine the effect of the degree of physical exertion on the onset time distribution of aSAH. Multivariate analysis was used to calculate the odds ratio (OR) between the two groups to determine the effect of the degree of physical exertion on each set of time periods.RESULTS: There was a definite bimodal onset pattern that peaked at 08:00–12:00 hours followed by 16:00–20:00 hours (p <0.001). MET values at all time intervals were found to be significantly higher than the night time (00:00–04:00 hours) values (p<0.031). The MET value distribution showed a unimodal pattern that slightly differed from the bimodal distribution of the onset time of aSAH. There were no significant differences in the ORs of each time interval according to the degree of the MET value.CONCLUSION: This study reaffirmed that aSAH occurs in a bimodal pattern, especially showing the highest prevalence in the morning. Although aSAH could be related to daily activity, there were no significant changes in diurnal variations affected by the degree of physical exertion.

Relationship between Circadian Variation in Ictus of Aneurysmal Subarachnoid Hemorrhage and Physical Activity

OBJECTIVE: The circadian pattern of the onset time of aneurysmal subarachnoid hemorrhage (aSAH) has been reported by various authors. However, the effect of the degree of physical exertion on the circadian pattern has not been studied in detail. Therefore, we conducted this study to investigate the effect of physical exertion on the circadian pattern of aSAH. METHODS: Of the 335 patients presenting with aSAH from January 2012 to December 2017, 234 patients with identifiable onset time and metabolic equivalent (MET) values were enrolled. The onset time of aSAH was divided into 4-hour intervals. The patient’s physical exertion was then assessed on a scale between 1 and 8 METs using generally accepted MET values, and categorized into two groups—light exertion (1 to 4 METs) and moderate to heavy exertion (5 to 8 METs)—to determine the effect of the degree of physical exertion on the onset time distribution of aSAH. Multivariate analysis was used to calculate the odds ratio (OR) between the two groups to determine the effect of the degree of physical exertion on each set of time periods. RESULTS: There was a definite bimodal onset pattern that peaked at 08:00–12:00 hours followed by 16:00–20:00 hours (p <0.001). MET values at all time intervals were found to be significantly higher than the night time (00:00–04:00 hours) values (p<0.031). The MET value distribution showed a unimodal pattern that slightly differed from the bimodal distribution of the onset time of aSAH. There were no significant differences in the ORs of each time interval according to the degree of the MET value. CONCLUSION: This study reaffirmed that aSAH occurs in a bimodal pattern, especially showing the highest prevalence in the morning. Although aSAH could be related to daily activity, there were no significant changes in diurnal variations affected by the degree of physical exertion.

Does Neurosurgical Clipping or Endovascular Coiling Lead to More Cases of Delayed Hydrocephalus in Patients with Subarachnoid Hemorrhage?

OBJECTIVE: We investigated whether clipping or endovascular treatment (EVT) can reduce the incidence of delayed hydrocephalus. We also investigated whether additional procedures, namely lumbar drainage and extra-ventricular drainage (EVD), decrease the incidence of delayed hydrocephalus in patients with subarachnoid hemorrhage (SAH). MATERIALS AND METHODS: One-hundred and fifty-two patients who had undergone an operation for SAH were enrolled in this study. Clinical data, radiological data, and procedural data were investigated. Procedural data included the operating technique (clipping vs. EVT) and the use of additional procedures (no procedure, lumbar drainage, or EVD). Delayed hydrocephalus was defined as a condition in which the Evan's index was 0.3 or higher, as assessed using brain computed tomography more than 2 weeks after surgery, requiring shunt placement due to neurological deterioration. RESULTS: Of the 152 patients, 45 (29.6%) underwent surgical clipping and 107 (70.4%) underwent EVT. Twenty-five (16.4%) patients developed delayed hydrocephalus. Age (p = 0.019), procedure duration (p = 0.004), and acute hydrocephalus (p = 0.030) were significantly correlated with the incidence of delayed hydrocephalus. However, the operation technique (p = 0.593) and use of an additional procedure (p = 0.378) were not significantly correlated with delayed hydrocephalus incidence. CONCLUSION: No significant difference in the incidence of delayed hydrocephalus was associated with operation technique or use of an additional procedure in patients with SAH. However, delayed hydrocephalus was significantly correlated with old age, long procedural duration, and acute hydrocephalus. Therefore, we recommend that additional procedures should be discontinued as soon as possible.

Clopidogrel Response Variability in Unruptured Intracranial Aneurysm Patients Treated with Stent-Assisted Endovascular Coil Embolization : Is Follow-Up Clopidogrel Response Test Necessary?

OBJECTIVE: The purpose of this study was to analyze the variability of clopidogrel responses according to duration of a clopidogrel drug regimen after stent-assisted coil embolization (SAC), and to determine the correlation between the variability of clopidogrel responses and thromboembolic or hemorrhagic complications.METHODS: A total of 47 patients who underwent SAC procedures to treat unruptured intracranial aneurysms were enrolled in the study. Preoperatively, patients received more than seven days of aspirin (100 mg) and clopidogrel (75 mg), daily. P2Y12 reaction unit (PRU) was checked with the VerifyNow test one day before the procedure (pre-PRU) and one month after the procedure (post-PRU). PRU variability was calculated as the difference between the initial response and the follow-up response. Patients were sorted into two groups based on their response to treatment : responsive and hypo-responsive.RESULTS: PRU variability was significantly greater in the hypo-responsive group when compared to the responsive group (p=0.019). Pre-PRU and serum platelets counts were significantly correlated with PRU variation (p=0.005 and p=0.004, respectively). Although thromboembolic complication had no significant correlated factors, hemorrhagic complication was correlated with pre-PRU (p=0.033).CONCLUSION: In conclusion, variability of clopidogrel responses during clopidogrel medication was correlated to serum platelet counts and the initial clopidogrel response. Thromboembolic and hemorrhagic complications did not show correlation with the variability of clopidogrel response, or the clopidogrel response after one month of medication; however, hemorrhagic complication was associated with initial clopidogrel response. Therefore, it is recommended to test patients for an initial clopidogrel response only, as further tests would be insignificant.

Clopidogrel Response Variability in Unruptured Intracranial Aneurysm Patients Treated with Stent-Assisted Endovascular Coil Embolization : Is Follow-Up Clopidogrel Response Test Necessary?

OBJECTIVE: The purpose of this study was to analyze the variability of clopidogrel responses according to duration of a clopidogrel drug regimen after stent-assisted coil embolization (SAC), and to determine the correlation between the variability of clopidogrel responses and thromboembolic or hemorrhagic complications. METHODS: A total of 47 patients who underwent SAC procedures to treat unruptured intracranial aneurysms were enrolled in the study. Preoperatively, patients received more than seven days of aspirin (100 mg) and clopidogrel (75 mg), daily. P2Y12 reaction unit (PRU) was checked with the VerifyNow test one day before the procedure (pre-PRU) and one month after the procedure (post-PRU). PRU variability was calculated as the difference between the initial response and the follow-up response. Patients were sorted into two groups based on their response to treatment : responsive and hypo-responsive. RESULTS: PRU variability was significantly greater in the hypo-responsive group when compared to the responsive group (p=0.019). Pre-PRU and serum platelets counts were significantly correlated with PRU variation (p=0.005 and p=0.004, respectively). Although thromboembolic complication had no significant correlated factors, hemorrhagic complication was correlated with pre-PRU (p=0.033). CONCLUSION: In conclusion, variability of clopidogrel responses during clopidogrel medication was correlated to serum platelet counts and the initial clopidogrel response. Thromboembolic and hemorrhagic complications did not show correlation with the variability of clopidogrel response, or the clopidogrel response after one month of medication; however, hemorrhagic complication was associated with initial clopidogrel response. Therefore, it is recommended to test patients for an initial clopidogrel response only, as further tests would be insignificant.

Correlation between Head Trauma and Outcome of Chronic Subdural Hematoma / 대한신경손상학회지

OBJECTIVE: Our study examined the prognostic factors involved in the outcome of patients with chronic subdural hematoma (CSDH) who had undergone burr hole drainage procedures, and investigated the association between outcome and traumatic head injury. In addition, we explored factors related to recurrence. METHODS: This study enrolled 238 patients with CSDH who had undergone burr hole drainage. Patients with history of head injury were categorized into the head trauma group and were compared with the no head trauma group. Outcome was considered good when modified Rankin Scale scores improved from admission to discharge and the final follow-up. RESULTS: Among 238 patients, 127 (53.4%) were included in the head trauma group. One hundred thirty-three (55.9%) patients demonstrated good outcome at discharge, and 171 (71.8%) patients demonstrated good outcome at the final follow-up. None of the factors examined was significantly correlated with good outcome at discharge. However, only history of head injury (p=0.033, odds ratio 0.511, 95% confidence interval 0.277-0.946) was significantly correlated with poor outcome at long-term follow-up. Recurrence occurred in 20 (8.4%) cases in the total cohort and 11 (55%) patients in the head trauma group. CONCLUSION: History of head trauma is correlated with poor outcome at long-term follow-up in CSDH patients having undergone burr hole drainage. Therefore, CSDH patients with history of head injury are susceptible to poor outcome, warranting more careful evaluation and treatment after burr hole drainage.

A Case of Intracranial Wooden Foreign Body: Mimicking Pneumocephalus / 대한신경손상학회지

Intracranial wooden foreign bodies are rare. In addition, such objects are difficult to identify with conventional radiographic techniques, such as X-ray radiography or brain computed tomography. A 48-year-old man presented to our emergency room with a headache. Even though he had a history of trauma, he had no external wounds and showed no neurological deficits at the initial examination. He was initially diagnosed with trauma-related pneumocephalus. He developed a delayed intracranial infection and underwent surgery to remove the wooden foreign body. The present case illustrates the necessity for special attention to patients suspected of having pneumocephalus with a rare presentation during the initial examination. Early surgical removal of the intracranial foreign body is necessary to prevent complications.

Syringomyelia Associated with a Huge Retrocerebellar Arachnoid Cyst: A Case Report

Occasionally, a posterior fossa arachnoid cyst can induce compression of the spinal cord and cause syringomyelia. Here, we report the case of a 29-year-old man with both progressive shoulder pain and gait disturbance, who was found to have a huge retrocerebellar arachnoid cyst associated with syringomyelia. Accordingly, posterior fossa decompression and arachnoid cyst excision were performed. Post-operative MRI showed a marked reduction in the size of the arachnoid cyst and syringomyelia. The patient's symptoms were clearly improved compared to before surgery. In our view, treatment in such patients should focus on decompressing the foramen magnum and include the removal of the coexistent arachnoid cyst walls, which appear to be the crucial factor in development of syringomyelia. In this report, we discuss the pathogenic mechanisms underlying syringomyelia-associated retrocerebellar arachnoid cyst and review the current literature on this topic.

Accuracy of Pedicle Screw Insertion Using Fluoroscopy-Based Navigation-Assisted Surgery : Computed Tomography Postoperative Assessment in 96 Consecutive Patients

OBJECTIVE: Two-dimensional fluoroscopy-based computerized navigation for the placement of pedicle screws offers the advantage of using stored patient-specific imaging data in providing real-time guidance during screw placement. The study aimed to describe the accuracy and reliability of a fluoroscopy-based navigation system for pedicle screw insertion. METHODS: A total of 477 pedicle screws were inserted in the lower back of 96 consecutive patients between October 2007 and June 2012 using fluoroscopy-based computer-assisted surgery. The accuracy of screw placement was evaluated using a sophisticated computed tomography protocol. RESULTS: Of the 477 pedicle screws, 461 (96.7%) were judged to be inserted correctly. Frank screw misplacement [16 screws (3.3%)] was observed in 15 patients. Of these, 8 were classified as minimally misplaced (4 mm). No complications, including nerve root injury, cerebrospinal fluid leakage, or internal organ injury, were observed in any of the patients. CONCLUSION: The accuracy of pedicle screw placement using a fluoroscopy-based computer navigation system was observed to be superior to that obtained with conventional techniques.

Chronic Subdural Hematomas: Comparison between Unilateral and Bilateral Involvement / 대한신경손상학회지

OBJECTIVE: Chronic subdural hematoma (CSDH) is a common intracranial hemorrhage, encountered in neurosurgical practice. Most CSDHs are unilateral, but some show bilateral involvement. However, the clinical characteristics of bilateral CSDH remain unclear. In this study, we investigated the clinical differences between bilateral and unilateral CSDH. METHODS: A retrospective study was performed on 120 patients with CSDH surgically treated at our institute from January 2008 to December 2012. Patients were divided into two groups: the bilateral CSDH and the unilateral CSDH groups. Clinical presentations, precipitating factors, computed tomography (CT) findings, postoperative complications, and outcomes of patients were analyzed. RESULTS: Bilateral CSDH was identified in 11 of 120 (10.9%) patients with CSDH. Patients with bilateral CSDH tended to have a lower rate of head injury compared to patients with unilateral CSDH (36.4% vs. 59.6%), but it had no statistical significance (p=0.201). The frequency of marked midline shift on CT scans was significantly greater in unilateral CSDH than in bilateral CSDH (p=0.010). Presenting symptoms, coexisting systemic diseases, postoperative complications, and clinical outcomes were not significantly different between the two groups. CONCLUSION: Bilateral CSDH has comparatively similar clinical features and precipitating factors as unilateral CSDH. Patients with bilateral CSDH have significantly lower incidences of midline shift on CT scans, and most patients with either bilateral or unilateral CSDH have good postoperative outcomes.

Clinical and Radiologic Results of Endovascular Coil Embolization for Cerebral Aneurysm in Young Patients / 신경중재치료의학

PURPOSE: This study is an overview of the clinical and radiologic outcomes of endovascular coil embolization for cerebral aneurysm in patients aged 40 years and younger. MATERIALS AND METHODS: Between January 2008 and June 2011, 218 aneurysms were treated using endovascular coil embolization and followed up with cerebral angiography at least six months later. Twenty-one aneurysms occurred in patients aged 40 years and younger, while 197 occurred in 179 patients older than 40 years. The clinical and radiologic results were retrospectively analyzed and compared between the two groups using the modified Rankin scale scores and the modified Raymond scale. RESULTS: Follow-up cerebral angiography revealed two (9.5%) major and two (9.5%) minor recanalized aneurysms in patients aged 40 years and younger, and six (3.0%) major and 35 (17.7%) minor recanalized aneurysms in patients older than 40 years. However, the differences between the groups were not statistically significant. The preoperative and postoperative mean modified Rankin scale scores at time for follow-up angiography were 1.14 and 0.19 respectively for patients aged 40 years and younger, and 1.30 and 0.30 respectively for patients older than 40 years. CONCLUSION: The younger patients had clinically favorable outcomes with tolerable angiographic follow-up results. More regular and long-term imaging follow-up is required for younger patients due to their longer life expectancy.

Endovascular Coil Embolization of Distal Anterior Cerebral Artery Aneurysms: Angiographic and Clinical Follow-up Results / 신경중재치료의학

PURPOSE: This study is an overview of the clinical and angiographic outcomes of patients who undergo treatment for distal anterior cerebral artery aneurysms. MATERIALS AND METHODS: Between January 2009 and March 2012, 444 cerebral aneurysms were treated using endovascular coil embolization at our institute. Among them, 217 aneurysms were followed-up with angiography at least six months later. Of these, there were 16 distal anterior cerebral artery (ACA) aneurysms in 16 patients. We conducted a retrospective review of clinical and radiological follow-up results of all patients with distal ACA aneurysms. The clinical and angiographic outcomes were assessed using the modified Rankin scale (mRS) and the Raymond classification scale, respectively. RESULTS: The mean age was 54.7 +/- 10.2 years (41-75 years). The mean follow-up period was 20.6 +/- 9.64 months (6-37 months). Three patients presented with acute rupture. The average aneurysm size was 4.98 +/- 1.39 mm (3.0-8.1 mm), and eight of 16 aneurysms (50%) had aspect ratios < 2.0. All 16 patients presented with complete obliteration immediately after the procedure. However, two patients had procedure-related complications, one with coil extrusion to the subarachnoid space without hemorrhage and one with thromboembolism subsequent to chemical thrombolysis. In the follow-up angiography, one major and five minor recurrences (for a total of six recurrences, 37.5%) were detected. However, the differences between the ACA aneurysm group and others were not statistically significant. Clinical outcomes were good for all of the patients at the time of discharge (mean mRS: 0.25, 0 to 1) and at the follow-ups (mean mRS: 0). CONCLUSION: Despite a comparatively high recurrence rate, the endovascular treatment of distal anterior cerebral aneurysms is feasible and has a good clinical outcome.

Delayed Onset of Spinal Subdural Hematoma after Vertebroplasty for Compression Fracture: A Case Report

Vertebroplasty (VP) is a well-known therapeutic modality used to treat pain associated with vertebral compression fractures. Major complications such as cord or root compression, epidural and subdural hematomas (SDH) and pulmonary emboli, occur in less than 1% of patients who undergo VP after compression fracture. Spinal SDH is an extremely rare complication that usually happens a few hours after the procedure. We report a case of spinal SDH that developed at two weeks after a successful VP. We also reviewed related literatures and discussed its possible pathogenesis.

Comparisons of Two-level Discectomy and Fusion with Cage Alone versus Single-level Corpectomy and Fusion with Plate in the Treatment of Cervical Degenerative Disc Disease

OBJECTIVE: To compare the radiologic parameters and clinical outcomes of two-level anterior cervical discectomy and fusion (ACDF) with cage alone versus single-level anterior cervical corpectomy and fusion (ACCF) with plate in the treatment of two-level contiguous cervical degenerative disc disease. METHODS: Of all 38 consecutive patients who were included in this study, 22 patients underwent on a two-level contiguous ACDF with cage alone (ACDF-CA group), 16 patients underwent a single-level ACCF with plate (ACCF-P group). We compared following parameters between these two groups; perioperative parameters (hospital stays, blood loss and operation duration), clinical parameters (Japanese Orthopedic Association scores and Odom's criteria) and radiologic parameters segmental height ratio (SHR), segmental lordotic angle (SLA), global lordotic angle (GLA) and fusion rate). RESULTS: The amount of operative blood loss in the ACCF-P group was higher than in the ACDF-CA group with statistical significance (p<0.05). Clinical outcomes and fusion rates were similar between groups. The postoperative SHRs in both groups were higher than that of preoperative period with statistical significance; however, these values significantly decreased at the last follow up period. The SLA increased during the immediate postoperative period, and then mild decreased. The values of GLA in both groups did show variable differences according to each time frame. CONCLUSION: The results of ACDF-CA were comparable with ACCF-P with regard to clinical and radiologic outcomes in contiguous two-level cervical fusion. A two-level ACDF-CA as a treatment modality for two-level contiguous cervical disc disease may be a worthwhile method as an alternative to single-level ACCF-P.

Hemorrhagic Lumbar Synovial Cyst

Synovial cysts of the lumbar spine are an uncommon cause of back and radicular pain. These cysts most frequently present as back pain, followed by chronic progressive radiculopathy or gradual onset of symptoms secondary to spinal canal compromise. Although less common, they can also present with acute spinal cord or root compression symptoms. We report of a case in which hemorrhaging into a right L2-3 facet synovial cyst caused an acute onset of back pain and radiculopathy, requiring surgical excision.

The Efficacy of Simultaneous Bilateral Internal Carotid Angiography during Coil Embolization for Anterior Communicating Artery Aneurysms

OBJECTIVE: Successful coil embolization of anterior communicating (A-com) artery aneurysms requires good visualization and understanding of the entire H complex. Bilateral carotid angiography may optimize anatomical understanding and visualization of the H complex. We therefore assessed the efficacy of simultaneous bilateral internal carotid angiography during coil embolization for A-com artery aneurysms. METHODS: Of the 153 patients with intracranial saccular aneurysms who underwent embolization between July 2008 and December 2009, 12 had A-com artery aneurysms and were embolized under bilateral carotid angiography. Patients were evaluated angiographically, immediately and 6 months (n=11) after embolization, using a 3-point scale (complete, residual neck, residual aneurysm). The safety, performance and efficacy of this approach were retrospectively evaluated. RESULTS: In all patients, bilateral internal carotid artery angiography provided more detailed anatomical information and understanding around the A-com artery, and, in complex situations, it allowed for more effective coil embolization through bilateral routes to the A-com artery. Angiography immediately after embolization showed occlusion of 11 of the 12 (92%) aneurysms, with none of these 11 showing evidence of recanalization at 6 months. CONCLUSION: These findings indicate that simultaneous bilateral carotid angiography during coil embolization of selected complex A-com artery aneurysms provided improved anatomical understanding, and resulted in more effective and safer procedures than typical unilateral angiography.

A Bilateral Internal Carotid Angiography-Based Neck Remodelling Technique for Anterior Communicating Artery Aneurysms: Technical Notes / 대한뇌혈관외과학회지

We report three cases of a novel balloon remodelling technique across the anterior communicating artery (ACoA) through simultaneous bilateral internal carotid angiography. In all three cases, simultaneous bilateral carotid angiography for balloon-assisted coil embolisation of anterior communicating artery aneurysms (ACoAA) provided improved anatomical detail and resulted in effective and safe procedures compared to typical unilateral angiography.

Lumbar Disc Herniation Associated with Severe Scoliosis in Young Age: Report of Three Cases

Intervertebral disc herniation is rare in adolescence, although several cases have been reported in the literature. We present three cases of lumbar disc herniation with low back pain and severe scoliosis (Cobb angle greater than 20 degrees). The patients had no prior history of trauma or collagen disease. Preoperative MRI scans showed L3-L4 (case 1), L4-L5 (case 3) and L5-S1 (case 2) disc herniations with no other bony or structural changes. Following discectomy, patient pain resolved, and scoliosis improved without further treatment. We conclude that severe scoliosis associated with disc herniation in young patients is likely secondary to pain and is not indicative of further structural changes.

The Organ Donation Rates in the Neurosurgical Field: Preliminary Study in a Single Institute / 대한이식학회지

BACKGROUND: In this study, we analyzed the brain death patients and the donation rates in our neurosurgical field and we discuss the factors that may be important for maximizing these rates by review of literatures. METHODS: We performed a retrospective reviews of 3,016 patients who were admitted into the neurosurgical intensive care unit (NICU) from January 1, 2003 till December 31, 2008. RESULTS: A total of 300 deaths in the NICU was recorded. The major cause of death was cerebral lesion (92%, n=276). Among these deaths, the cerebral lesion was caused by hemorrhage (59%, n=176) and trauma (33%, n=100). The number of the medically or clinically suitable organ donors was 58 cases (19% of all deaths). Organ donation was realized in 37 cases (64% of all the potential donors). Among the non-donation cases, 16 cases refused organ donation, corresponding to a refusal rate of 28%. Two cases were not suitable due to infection, one case was not suitable due to early death, and two cases were not suitable due to legal problems. CONCLUSIONS: Despite that Koreans overwhelmingly support organ donation and transplantation, the actual donation rate remain low. The organ donation rate of our city as 10 PMP was higher than that of whole country last year. As a preliminary study, it will be necessary to analyze the difference of organ donation rate between our city and other cities to identify predictors to affect on donation.

Early Rebleeding after Internal Trapping of a Ruptured Vertebral Artery Dissecting Aneurysm: A Case Report / 신경중재치료의학

Subarachnoid hemorrhage (SAH) from vertebral artery (VA) dissecting aneurysms is rare and potentially fatal. Early rebleeding from ruptured VA dissecting aneurysms excessively reduces favorable outcome rates of the ruptured dissecting aneurysms, so that early diagnosis and treatment are essential for preventing early rebleeding and devastating results. A 52-year-old man was referred to our hospital due to an abruptly developed severe headache and sequential mental change. SAH due to ruptured left VA dissecting aneurysm was noted. We performed early endovascular internal trapping, and successful flow arrest on final angiogram was confirmed. About 6 hours later after internal trapping of the aneurysm, his mentality abruptly deteriorated and rebleeding was confirmed. We present this case of early rebleeding from vertebral dissecting aneurysm after endovascular internal trapping, along with a literature review.